Saving Face Strategies to avoid skin breakdown during NIV Hospital - PowerPoint PPT Presentation

Saving Face Strategies to avoid skin breakdown during NIV Hospital Respiratory Care Education Department August 02, 2011

Focal areas NIV Complications Patient Assessment Wound Reduction 2 Education Department, August 02, 2011

Noninvasive ventilation “There is arguably more evidence to support the use of noninvasive ventilation (NIV) than any other practice related to the care of patients with acute respiratory failure” 1 NIV can also be associated with skin breakdown, leading to formation of hospital-acquired pressure sores 1 Hess, D .; Patient –ventilator interaction during noninvasive ventilation . Respir Care 2011; 56(2):153:165 3 Education Department, August 02, 2011

NIV Complications Incidence of skin breakdown • “Among the adverse effects of mask ventilation, skin breakdown, which occurs at the site of mask contact even after only a few hours of ventilation, is a frequent complication, ranging from 2-23%” 1 • “In one study, where patients were continuously ventilated with a face mask for more than 48 hours, this percentage reached 70%” 1 1 Gregoretti et al. Evaluation of patient skin breakdown and comfort with a new face mask for non- invasive ventilation: a multi-center study. Inten Care Med 2002 ; 28:278-284. 4 Education Department, August 02, 2011

NIV Complications CMS reimbursement changes • CMS classified Stage III and IV pressure ulcers as a preventable Hospital Acquired Condition (HAC) 1 • No longer reimbursed by current insurance guidelines 1 • Focal topic at the 2011 National Pressure Ulcer Advisory Panel (NPUAP) Meeting 1 1 http://www.cms.hhs.gov 5 Education Department, August 02, 2011

NIV Complications Pressure ulcers • Localized areas of tissue necrosis • Develop when soft tissue is compressed between a boney prominence surface for an extended period of time Most common on Extreme cases involve bridge of nose surrounding areas 6 Education Department, August 02, 2011

NIV Complications Pressure tolerance 1 • Shearing forces cause stretching, kinking, and tearing in the subcutaneous tissues leading to deeper tissue necrosis • Compressive pressure should be < diastolic BP – Secondary goal is < capillary BP (32-45 mmHg) – Duration of pressure exposure is extremely important – Pressure increases markedly over bony prominences Shearing forces DeFloor, T. The risk of pressure sores: a conceptual scheme; Jour of Clin Nursing 1 999;8:206-216 7 Education Department, August 02, 2011

NIV Complications Skin anatomy and physiology • Epidermis – The outer layer of skin sheds every 21 days • Dermis – Contains nerve endings, blood vessels, oil glands, and sweat glands – It also contains collagen and H elastin y p o • Hypodermis d e – The subcutaneous tissue is a r m layer of fat and connective i s tissue that houses larger www.npuap.org blood vessels and nerves 8 Education Department, August 02, 2011

NIV Complications Pressure ulcer - Stage 1 • Intact skin with non-blanchable redness • A change in the skin temperature (warm or coolness) • Tissue consistency (firm or boggy feel) • And/or sensation (pain or itching) www.npuap.org 9 Education Department, August 02, 2011

NIV Complications Pressure ulcer – Stage 2 • Partial thickness loss of skin involving epidermis and/or dermis • Presents as a intact or open serum filled blister or shallow crater www.npuap.org 10 Education Department, August 02, 2011

NIV Complications Pressure ulcer – Stage 3 • Full thickness tissue loss involving damage to or necrosis of subcutaneous tissue • May extend down to, but not through, underlying fascia • Presents as a deep crater which may include undermining or tunneling www.npuap.org 11 Education Department, August 02, 2011

NIV Complications Pressure ulcer – Stage 4 • Full thickness tissue loss with extensive destruction • Exposed bone, muscle or tendon • Some slough or eschar may be present www.npuap.org 12 Education Department, August 02, 2011

Patient Assessment Initial assessment • All patients should be assessed for skin integrity on admission • Assessment of risk factors for HAPU should also be determined on admission and prior to NIV initiation – Braden scale • Relative risk should determine monitoring frequency and prevention strategy 13 Education Department, August 02, 2011

Patient Assessment Assessment and documentation • Risk assessment before starting NIV • Assess all potential areas for redness that could be impacted by respiratory devices • Assess redness or open wounds; report findings to the primary registered nurse • Document on the respiratory flow sheet or the treatment plan if a wound or red area is present • Document off-loading and/or implementation of protective devices 14 Education Department, August 02, 2011

MD ORDER FOR BIPAP Patient Assessment Huddle with Nursing (Protocol granted with permission) Skin Breakdown Risk Factors Should any of the following criteria apply the patient is at HIGH RISK □ Vasopressors □ Chronic steroid therapy □ Fragile or edematous skin on face OR A patient who has any FOUR of the following criteria should be considered HIGH RISK: □ Malnutrition □ 60yo □ DM □ Dehydration □ Dialysis □ Anatomical factors ( Bony prominences) □ Current skin breakdown elsewhere on body □ DNR □ Restraints □ COPD □ Neurological Impairment □ Braden Scale 18 Perform & Document Skin Integrity Risk Apply Alternative Bipap Masks Yes ? Assessment High Risk No ? ● Total Face Mask ● Gel Face Mask Initiate Standard Face Mask ● Alternate between Total + full Masks Q4. INITIATE BIPAP BUNDLE Pass? Go 1. Perform Subsequent Skin Assessment/document (Q2). Notify Supervisor to step 3 and remove 2. Perform Appropriate Mask Sizing + documented from service. Fail? 3. Perform Exhalation Port Test. 4. Apply Facility Approved protective foam dressing. Subsequent Skin Assessments Skin Integrity Risk Assessment 5. Perform/Assess Mask Leak. 1. Check for redness, 1.Remove or lift protective tearing, discoloration, foam dressing. breakdown, etc. 2. Check for redness, tearing, a. If present notify RN/ discoloration, breakdown, etc Adjust mask and loosen if wound care. Leak <10? a. If present notify RN/ necessary. 2. Document Findings Wound care. and Individual notified . 3. Document findings and individual notified. Proceed and monitor Leak >10 but <25? as indicated 15 Education Department, August 02, 2011

Patient Assessment Education Department, August 02, 2011

Patient Assessment Clinical considerations • Clinicians remove and reposition masks many times per day 1 – Mouth Care – Medication administration – Hydration – Mask breaks • Select a mask that can be easily repositioned correctly 1 Hilbert et al. Noninvasive ventilation for acute respiratory failure. Quite low time consumption for nurses Eur Respir J 2000; 16:710-716 17 Education Department, August 02, 2011

Patient Assessment Choose the right mask design Up to 50% of NIV failures are related to the mask 1 1 Nava et al. Interfaces and humidification for noninvasive ventilation; Respir Care 2009 ; 54:71-82 Education Department, August 02, 2011

Patient Assessment Mask selection considerations • Estimated length of use • Compatibility with device • Safety features – Quick release clips – Anti-asphyxia valves • Facial features – Skin condition – Facial abnormalities Education Department, August 02, 2011

Patient Assessment Patient selection considerations • Mouth breather • Claustrophobic • Level of consciousness • Cooperation • Facial structure Education Department, August 02, 2011

Patient Assessment Mask selection considerations • Mask types – Total face mask – Oro-nasal face mask – Nasal mask – Nasal prongs • Headgear selection – Four-point straps – CapStrap • Soft, self-sealing cushions – Balanced pressure on nose, chin, and forehead • Anti-asphyxia features Education Department, August 02, 2011

Wound Reduction Airflow and pressure-related complications of NIV Adverse Effect Remedy Nasal congestion Try humidification or speak to the physician for various remedies to assist with this problem Nasal or oral dryness Add humidification, nasal saline, oral/nasal hygiene, or decrease leak Sinus or ear pain Lower inspiratory pressure Gastric inflation Avoid excessive inspiratory pressures (over 20 cmH 2 O) Eye irritation Check mask fit, readjust bottom headgear straps Failure to ventilate Use sufficient pressures, optimize patient- ventilator synchrony Education Department, August 02, 2011

Wound Reduction Mask-related complications of NIV Adverse Effect Remedy Discomfort Check fit, adjust straps, change mask Excessive air leaks Realign mask, check strap tension, change to full face mask Nasal bridge redness or Use artificial skin, minimize strap tension, use ulceration spacer, alternate mask or use a PerforMax or Total face mask Skin irritation or rashes Use skin barrier lotion and/or topical corticosteroids, change to mask made from a different material, properly clean mask Claustrophobic reactions Try nasal mask or PerforMax or Total face mask, sedate judiciously Education Department, August 02, 2011